Yes. Participating providers must get pre-service, preauthorization review for inpatient facility services for out-of-area BlueCard® members, when it is required by the member’s subscriber certificate or the account. If you don’t get preauthorization review, the facility will be held financially responsible.
If the member’s primary insurer is Blue Cross Blue Shield, you must contact the Local plan. The Local plan is responsible for processing the claim.
Based on our contractual arrangement with you, you may not balance bill the BlueCard member for the difference between our allowance and your charge.
BlueCard Program claims we process will appear on your Provider Detail Advisory (PDA) and Provider Payment Advisory (PPA). The PDA will indicate any co-insurance or deductibles you can collect directly from the member.
After the member’s plan applies benefit and eligibility information, we adjudicate the claim according to your contracted Agreement with us. We will reimburse you as part of our normal payment cycles provided that the member is eligible, the services are covered, and you have not already been paid for your services.
PPO and EPO members
Yes. The BlueCard managed care or point-of-service (POS) program is designed for national account members who live or work in Massachusetts but whose Home plan is in another state. To use the program, the national account member selects a primary care provider who is enrolled in the HMO Blue network. These members are subject to all the same referral practices, medical policies, and network protocols as a standard Blue Choice POS member.